Abstract: At 4:00 p.m. on April 9, 2019, an employee was working for a firm that manufactured and packaged, under contract, liquid products for such personal care categories as deodorants, bath and body, and skin care. It was a consumer and automotive packaging company that specialized in the packaging of liquids and gels. The company operated a multitude of automated product lines and machinery that required adjustments and maintenance. In order for employees to conduct these operations, specific lockout/tagout procedures had been developed to ensure that there was no potential for accidental start up when employees were exposed to the hazardous operations of the machines. The employee was working as a line technician. He was responsible for machine setup and adjustments to the machines for anything short of repair. He was completing a common task for line technicians: manually adjusting the torque wheels of the capper section of line Number 3. He had opened up the guard doors to the capper section and was making adjustments as the machine ran. While making the adjustments, he noticed that a bottle had fallen. He reached over to upright the bottle. As he did this, his fingers were caught in the chain and sprocket of the machine's rear drive chain. Three of his fingers were caught in the chain and sprocket. The location of the nip point was 0.64 meters (25 inches) from the opening of the guard. There was also a nearer chain, located 0.23 meters (9 inches) from the opening. He suffered either a partial or complete amputation of the small finger and severe lacerations of the ring and middle fingers, all on his right hand. He was hospitalized. At the time of the incident, the specific procedure did not account for the pneumatic energy source of the machine and only advised the isolation of the electrical energy source.